Healthcare Provider Details

I. General information

NPI: 1518362227
Provider Name (Legal Business Name): AMY DECLERK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LEXINGTON AVE STE 400
FORT SMITH AR
72901-5170
US

IV. Provider business mailing address

500 SW 7TH ST STE A205
RENTON WA
98057-2983
US

V. Phone/Fax

Practice location:
  • Phone: 877-522-1275
  • Fax: 509-491-3031
Mailing address:
  • Phone: 877-522-1275
  • Fax: 833-888-7145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA004229
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberF1014430
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: